HealthFirst for Clinton County (Ohio)

Donor Information (please print or type)

Name _____________________________________

Address __________________________________

City _______________________________________

State ______________________________________

 Zip Code _________________________________

Phone  ____________________________________

Email _____________________________________

Pledge Information
I (we) pledge a total of $____________________ to be paid: ☐now ☐monthly ☐quarterly ☐yearly.

I (we) plan to make this contribution in the form of: ☐cash ☐check

Gift will be matched by (company/family/foundation)                                            
☐form enclosed☐form will be forwarded

Acknowledgement Information
Please use the following name(s) in all acknowledgements: ________________________________________________________________                                   
                                                                                                                                             
☐ I (we) wish to have our gift remain anonymous.
 
 Signature(s) __________________________________________________ Date ___________
 
Please make checks, corporate matches,
or other gifts payable to:
 
HealthFirst for Clinton County
Clinton County Foundation
POB 831
Wilmington, Ohio 45177